Wk 29 - ADHD in practice Flashcards
What is ADHD?
Developmental condition of inattention + distractibility, w/ or w/o accompanying hyperactivity
What are the 3 basic forms of ADHD?
- Predominantly inattentive
- Predominantly hyperactive/impulsive
- Combined
Which gender does ADHD most affect?
Boys
When is ADHD normally diagnosed?
3-7yrs
What are the primary symptoms ADHD?
- Inattentive
- Hyperactive
- Impulsive
Give examples of inattentive
- Short attention span
- Easily distracted
- Forgetful
- Unable to conc
Give examples of hyperactivity
- Unable to sit still
- Fidgeting
- Excessive movement + talking
Give examples of impulsiveness
- Unable to wait turn
- Acting w/o thinking
- Interrupting
Give examples of when ADHD is most common
- Preterm born
- Looked-after children
- Family w/ ADHD
- Neurodevelopmental disorders
- Acquired brain injury
- Known to youth justice system
- History of substance abuse
Give examples of related disorders that can occur alongside ADHD
- Anxiety
- Learning difficulties
- Tourettes
- Epilepsy
- Depression
- ODD
What is covered in primary care?
- Explore presenting problems
- Assess social + educational impact
- Waiting upto 10 wks
- Parent group based ADHD focused support
- Lifestyle advice + regular exercise
Who carries out formal diagnosis + treatment of ADHD?
Specialist
Outline the NICE guidelines for the management of ADHD in pre-school children
- Drugs not recommended
- Parent training/ed programme
- Specialist advice where ineffective
Outline the NICE guidelines for the management of ADHD in school-age + young people
- Drugs not 1st line
- Parent training/ed programme +/- CBT + social skills training
- Reserve drugs for when persistent impairment after env mods
- Methylphenidate 1st line
Outline the NICE guidelines for the management of ADHD in adults
- Env mod
- Drug treatment (methylphenidate/lisdexamfetamine) offered if ADHD symptoms cause sig impairment
- Non-pharm treatment considered alongside
What must be present when diagnosing?
- Core symptoms of hyperactivity, inattention + impulsivity
- Associated w/ least moderate psychological, social + educational or occupational impairment based on interview + obvs in multiple settings
- Pervasive, occuring in 2 settings: social, familial, educational + occupational
- Present for at least 6 months
Outline the drug therapy in order of lines
1st : methylphenidate
2nd: Lisdexamfetamine
3rd: Dexamfetamine
What is used to reduce drug misuse?
Lisdexamfetamine less abuse than dexamfetamine
Methylphenidate
- CD sched 2
- Inc intrasynaptic conc of dopamine + noradrenaline in frontal cortex
- Piperidine class
- Structure similar to amphetamine though less potent, pharmacological effect close to cocaine
What are the common adverse effects of methylphenidate?
- Insomnia
- Headache
- Dec appetite
- Tachycardia, minor inc BP
- Growth affected so monitor height + weight
- Sudden death syndrome
- Enhanced by alcohol
- Affect ability to drive
What are the monitoring points of methylphenidate?
Initiation + every 6 months:
- Pulse, BP
- Psychiatric symptoms
- Appetite, weight + height
How is methylphenidate intiated?
- CD requirement
- Low dose + titrate over 4-6wks until dose optimisation achieved
- Avoid abrupt w/drawal
- Can mix w/ food
- Prescribe by brand
What are the driving advice for amphetamines?
- Don’t drive if drowsy or dizzy or unable to conc
- Keep prescription in car as it is an offence to drive w/ more than specified amount in body
Dexamfetamine
- Sched 2
- Block uptake of dopamine + noradrenaline via dopamine transporter also releases dop + NA into extraneuronal space
- More potent than methylphenidate
- More misuse
- 6.8 elimination tf twice dosing = sufficient
Lisdexamfetamine
- Prodrug of dexamfetamine
- Sched 2
- Long lasting (13hrs)
- Less rebound symptoms
- Less abuse potential
- Improved adherence
Atomoxetine (strattera)
For when abuse = problem
What are the side effects of atomoxetine?
- Abdominal pain, dec appetite, nausea, irritability, mood swings
- Inc HR + BP
- Prolongs QT interval
- Hepatic disorders: recognise abdominal pain, darkening urine + jaundice
- Suicidal ideation
Outline the MHRA warning for atomoxetine
- CI: severe cardiovascular or cerebrovascular disorders
- Assess patient prior for cardiac disease
- Record HR + BP before treatment, after dose change then every 6 months
- Urgent referral to cardiac specialist
What must be monitored?
Prior to initiation + every 3-6 months:
- Pulse + after dose change
- BP + after dose change
- Weight
- Height in children + young people (dexamphetamine)
- Sleep disturbances
- Erectile dysfunction (atomoxetine)
- CDV assessment: refer to cardiology if cardiac history/risk
- Seizure freq
Give examples of what to do if weight loss is an issue
- Take med w/ or after food
- Additional snackers early morning or late eve when stimulant effect wear off
- Seek dietary advice
- Inc consumption of high calorie food w/ good nutritional value
- Change med
What are the key interactions of methylphenidate?
- Anticoagulants
- Carbamazepine
- MAOIs
- Phenytoin
- SSRIs
- TCAs
- Alcohol
What are the key interactions of amphetamines?
- Moclobemide
- MAOIs
- Rasagiline
- Atomoxetine
- TCAs
- SSRIs
- HIV protease inhibitors
What are the key interactions of atomoxetine?
- MAOIs
- Drugs that prolong QT interval
- Terbinafine
